Background: 
Extrapulmonary legionella infections are rare and usually occur in immunocompromised hosts. 

Case presentation summary: 
A 5 month-old male infant with history of recurrent oral thrush and candidiasis presented with multiple skin and liver abscesses. He was admitted for one month due to pneumonia and treated with intravenous meropenem and amikacin. Two weeks later, he developed multiple erythematous nodules with a high-grade fever and hepatomegaly.  Chest radiography showed perihilar and left lower lung infiltrates. Abdominal computer tomography revealed several ring enhancing hypodense lesions, ranging between 0.5-1.9 cm in size in both hepatic lobes. Incision and drainage was done and cefazolin was given without improvement. Meropenem and vancomycin intravenous therapy was started. Gram stain of pus from skin abscesses revealed gram-negative rods with multiple polymorphonuclear leucocytes but aerobic culture was negative. DNA-based identification performed by partial 16S rRNA gene sequencing revealed Legionella bozemanii with 99.7% identity. The patient was also diagnosed with severe combined immunodeficiency (SCID) [CD4+ T cells 0 cells/mm3, CD19+ 2,196 cells/mm3, low immunoglobulin]. Intravenous levofloxacin and immunoglobulin therapy were administered to the patient. He rapidly improved, becoming afebrile within 3 days and his abscesses healed within 2 weeks later. An abdominal ultrasound performed 3 weeks after levofloxacin therapy showed decreased size and number of lesions in both hepatic lobes. Levofloxacin was administered for a total of 19 weeks. 

Learning Points/Discussion: 
-This case highlights the importance of considering infections caused by Legionella spp. where multiple skin and liver abscesses not improved by beta-lactam antibiotic therapy. 
-Detection of Legionella DNA via PCR is a promising diagnostic technique. 
-High index of suspicious for primary immunodeficiency should be kept in an unusual infection and/or severe manifestation.

03 / A 5 MONTH-OLD MALE INFANT WITH MULTIPLE SKIN AND LIVER ABSCESSES DUE TO LEGIONELLA INFECTION